Background: Gastrointestinal food allergy (GIFA) occurs in 2 to 4 % of children, the majority of whom are infants (<1 year of age). Although endoscopy is considered the gold standard for diagnosing GIFA, it is invasive and requires general anaesthesia. Therefore, we aimed to investigate whether in infants with GIFA, gastrointestinal symptoms predict histological findings in order to help optimise the care pathway for such patients.

Methods: All infants <1 year of age over a 20 year period who underwent an endoscopic procedure gastroscopy or colonoscopy for GIFA were evaluated for the study. Symptoms at presentation were reviewed and compared with mucosal biopsy histological findings, which were initially broadly classified for study purposes as "Normal" or "Abnormal" (defined as the presence of any mucosal inflammation by the reporting pathologist at the time of biopsy).

Results: Of a total of 1319 cases, 544 fitted the inclusion criteria. 62 % of mucosal biopsy series in this group were reported as abnormal. Infants presenting with diarrhoea, rectal (PR) bleeding, irritability and urticaria in any combination had a probability >85 % (OR > 5.67) of having abnormal histological findings compared to those without. Those with isolated PR bleeding or diarrhoea were associated with 74 % and 68 % probability (OR: 2.85 and 2.13) of an abnormal biopsy, respectively. Conversely, children presenting with faltering growth or reflux/vomiting showed any abnormal mucosal histology in only 50.8 % and 45.3 % (OR: 1.04 and 0.82) respectively.

Conclusions: Food allergy may occur in very young children and is difficult to diagnose. Since endoscopy in infants has significant risks, stratification of decision-making may be aided by symptoms. At least one mucosal biopsy demonstrated an abnormal finding in around half of cases in this selected population. Infants presenting with diarrhoea, PR bleeding, urticaria and irritability are most likely to demonstrate abnormal histological findings.

Fig1: Frequencies of abnormal biopsy findings for single symptoms and combinations of symptoms common to two regression models

Mentions:
All biopsies were reported by specialist paediatric histopathologists from the same tertiary centre. For the purposes of this study, histopathological findings were coded as either “Normal” or “Abnormal” (presence of any significant abnormal finding at any biopsy site including acute or chronic inflammation, with or without increased mucosal eosinophil density [16], or other pathologies such as partial villous atrophy or Helicobacter pylori see Fig. 1). Chronic inflammation with predominantly excess mucosal eosinophil density was considered most suggestive of food allergy in this cohort of young children [12, 17, 18].

Fig1: Frequencies of abnormal biopsy findings for single symptoms and combinations of symptoms common to two regression models

Mentions:
All biopsies were reported by specialist paediatric histopathologists from the same tertiary centre. For the purposes of this study, histopathological findings were coded as either “Normal” or “Abnormal” (presence of any significant abnormal finding at any biopsy site including acute or chronic inflammation, with or without increased mucosal eosinophil density [16], or other pathologies such as partial villous atrophy or Helicobacter pylori see Fig. 1). Chronic inflammation with predominantly excess mucosal eosinophil density was considered most suggestive of food allergy in this cohort of young children [12, 17, 18].

Bottom Line:
Infants presenting with diarrhoea, rectal (PR) bleeding, irritability and urticaria in any combination had a probability >85 % (OR > 5.67) of having abnormal histological findings compared to those without.Those with isolated PR bleeding or diarrhoea were associated with 74 % and 68 % probability (OR: 2.85 and 2.13) of an abnormal biopsy, respectively.Infants presenting with diarrhoea, PR bleeding, urticaria and irritability are most likely to demonstrate abnormal histological findings.

Background: Gastrointestinal food allergy (GIFA) occurs in 2 to 4 % of children, the majority of whom are infants (<1 year of age). Although endoscopy is considered the gold standard for diagnosing GIFA, it is invasive and requires general anaesthesia. Therefore, we aimed to investigate whether in infants with GIFA, gastrointestinal symptoms predict histological findings in order to help optimise the care pathway for such patients.

Methods: All infants <1 year of age over a 20 year period who underwent an endoscopic procedure gastroscopy or colonoscopy for GIFA were evaluated for the study. Symptoms at presentation were reviewed and compared with mucosal biopsy histological findings, which were initially broadly classified for study purposes as "Normal" or "Abnormal" (defined as the presence of any mucosal inflammation by the reporting pathologist at the time of biopsy).

Results: Of a total of 1319 cases, 544 fitted the inclusion criteria. 62 % of mucosal biopsy series in this group were reported as abnormal. Infants presenting with diarrhoea, rectal (PR) bleeding, irritability and urticaria in any combination had a probability >85 % (OR > 5.67) of having abnormal histological findings compared to those without. Those with isolated PR bleeding or diarrhoea were associated with 74 % and 68 % probability (OR: 2.85 and 2.13) of an abnormal biopsy, respectively. Conversely, children presenting with faltering growth or reflux/vomiting showed any abnormal mucosal histology in only 50.8 % and 45.3 % (OR: 1.04 and 0.82) respectively.

Conclusions: Food allergy may occur in very young children and is difficult to diagnose. Since endoscopy in infants has significant risks, stratification of decision-making may be aided by symptoms. At least one mucosal biopsy demonstrated an abnormal finding in around half of cases in this selected population. Infants presenting with diarrhoea, PR bleeding, urticaria and irritability are most likely to demonstrate abnormal histological findings.